Introduction: This agreement is intended to provide you with important information regarding the practices, policies and procedures of THE FAMILY GUIDANCE AND THERAPY CENTER OF SOUTHERN CALIFORNIA and to seek your consent for evaluation services. If you are a parent of a minor client, then you will need to consent to this assessment prior to the commencement of services. Any questions or concerns regarding the contents of this Agreement should be discussed prior to signing it. Please read the entire document carefully and ask any questions before signing the document. In the event that you do not understand or do not consent to any aspect of this form, we can set a phone consultation to review this form. All sections must be consented to, as part of the ethical and legal requirements of professional therapy.

Please initial each section to indicate that you have read and understood that particular section.

Practice Information: The individual marital and family therapist who operates this practice is Jennifer Palmiotto. Her license number is #47375. This practice is a Licensed Marriage and Family Therapist Corporation: THE FAMILY GUIDANCE AND THERAPY CENTER OF SOUTHERN CALIFORNIA. This professional corporation operates under the fictitious business name of THE FAMILY GUIDANCE AND THERAPY CENTER OF SOUTHERN CALIFORNIA. The Family Guidance and Therapy Center of Southern California also practices using the DBA of "The Family Guidance and Therapy Center" and "FGTC."

Evaluation Information: The evaluation that you or your child will participate in may include, but not be limited to: cognitive testing, academic testing, mental health testing, social and emotional testing, review of records, school observations, interviews (including by telephone) of parents/ teachers / health care providers and other relevant persons, and completion of questionnaires. You will receive a written report of my findings. I will also provide copies to other requesting agencies, with your written consent.

Evaluator Background and Qualifications: I, Jessica A. Hobson, Ph.D., am a licensed clinical psychologist in the State of California. I conduct diagnostic and psychoeducational evaluations, as well as Independent Educational Evaluations in accordance with the Individuals with Disabilities Education Act (IDEA) and state law requirements. At your request, I will discuss my professional background information with you and provide you information regarding my experience, training, professional interests, and clinical orientation. You are free to ask questions at any time about my background, experience, and procedures.

Scope of Assessment: As an Independent Examiner, my interest in this matter is solely to provide the most accurate and comprehensive assessment of you or your child, addressing the questions/concerns asked of me to investigate. As such, I will approach this assessment without having any investment in the results. Neither the referral source nor the funding sources are relevant to the results, to the opinions that I reach, nor to the recommendations that I will make.

Risks and Benefits of Assessment: Participation in assessment can result in a number of benefits, including specific information that may be of use in educational and therapy planning, and understanding yourself and your child. Assessment results may also involve certain kinds of risks, which can include, but are not limited to, a particular diagnosis or recommendations that are unexpected or unpleasant. Most people find the benefits of an assessment of this type outweigh the risks. Please ask me questions at any time about any aspects of the assessment.

Professional Consultation: Professional consultation is an important component of a comprehensive evaluation practice. As such, I regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, I will not reveal any personal identifying information concerning you or your child.

Records and Record Keeping: I will keep records in accordance with the ethical and legal standards of my profession. Records may be requested at any time in writing. Records will be stored in a locked file cabinet and subsequently archived onto a HIPPA-compliant practice management software system.

Use of Practice Management Software: MyClientsPlus software is fully secure, confidential, encrypted, HIPAA-compliant practice management software.

E-mails, Cell Phones, Computers and Faxes: It is very important to be aware that computers and unencrypted e-mail, texts, and e-faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that go through them. While data on FGTC providers’ laptops is encrypted; e-mails and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. FGTC providers’ laptops are equipped with a firewall, a virus protection and a password, and providers back up all confidential information from their computers on a regular basis onto an encrypted hard-drive. Also, be aware that phone messages are transcribed and sent to FGTC providers via unencrypted e-mails. Please notify your FGTC provider if you decide to avoid or limit, in any way, the use of e-mail, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts or e-fax or via phone messages, FGTC will assume that you have made an informed decision, and will view it as your agreement to take the risk that such communication may be intercepted, and FGTC will honor your desire to communicate on such matters. Initial below if you consent to communicate by email, text and voicemail. Please do not use texts, e- mail, voice mail, or faxes for emergencies.

Notice of Privacy Practices: This practice is HIPAA compliant. Please indicate that you have received and signed the document named “Notice of Privacy Practices.” This document further explains how your medical information will be used by this practice.

Confidentiality: All communications between you and your psychologist are confidential and protected by law. I may not disclose confidential information about you or your child without your formal written consent. Our communication will be held in strict confidence unless you provide written permission to release information.

Exceptions to confidentiality: There are exceptions to confidentiality. Under these conditions, I am legally required to break confidentiality. These include a) If you or your child is in imminent danger of harming themselves; b) If there is imminent risk that you or your child intend to physically injure someone; or c) suspected child or elder abuse. In addition, a federal law known as The Patriot Act of 2001 requires psychologists, in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the patient that the FBI sought or obtained the items under the Act. In addition, I may be required by court order to release information as part of a legal proceeding.

Health insurance: Psychologists may have to share certain information about you or your child’s diagnosis or evaluation results with the health insurance company or government program that is paying for your treatment. Payers will ask for this information to verify that services were provided. These companies are also bound by HIPAA and must keep your information confidential.

Fees: Fees associated with the evaluation are dealt with in a separate contract for services. Responsible parties may include health insurance companies, parents / guardians, school districts, and legal representatives. If you are paying for this service out-of-pocket, monthly payments for service may be required. Payments can be completed by check, cash, or credit card. Payment arrangements should be discussed with FGTC when completing the contract for services.

Return Check Policy: You will be responsible for the amount of any returned checks plus a $17.00 returned check fee, to cover bank fees and administrative costs.

Emergencies: My office is equipped with a confidential voicemail system that allows a client to leave a message at any time. You may contact me at 707-774-6009. I will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. I am unable to provide 24-hour crisis service. In the event that you or your child is feeling unsafe or requires immediate medical or psychiatric assistance, they should call 911, or go to the nearest emergency room. In the event that I am unable to attend a scheduled appointment, I will contact you via your preferred method of communication.

Termination: You may end the evaluation at any time.

Questions or Complaints: If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Board of Behavioral Sciences or the Secretary of the Department of Health and Human Services, please contact me at the address on this form to discuss your concerns.

Acknowledgement: I have read and understood this document and I have had any questions answered to my satisfaction. I accept, understand, and agree to abide by the content and terms of this agreement and give my consent for 

to participate in this evaluation.